This week, the Oregon Secretary of State’s audit division released a comprehensive review of the state’s response to COVID-19 in nursing homes, memory care facilities and other types of long-term care.
Long-term care outbreaks accounted for 54% of all COVID-19 deaths in Oregon as of late February.
With more transmissible variants present in the state and Oregon still well below the threshold of vaccination needed to achieve herd immunity, the facilities — and their residents — remain vulnerable to the virus.
Related: Watch: Getting back to ‘normal’ in Oregon means getting to COVID-19 herd immunity
Here are three key findings from the report:
Missing data on vaccination rates
Residents in long-term care and their caregivers were among the first Oregonians to be eligible for the COVID-19 vaccine and more than 70,000 have received at least one dose, according to the CDC.
The facilities were a top priority for a simple reason: Their residents are the most at risk of dying from COVID-19.
Margene Haworth, left, receives a COVID-19 vaccination from McMinnville paramedic Elle Miller, Feb. 5, 2021 at Friendsview Retirement Community in Newberg, Ore.
Kristyna Wentz-Graff / OPB
Yet according to the auditor’s report, there’s been no requirement that individual facilities report their resident or staff vaccination rates to the state. And the pharmacies that have conducted vaccination campaigns for long-term care facilities aren’t reporting uptake rates to the state either.
Those pharmacies entered the names of the people they vaccinated into the state’s immunization registry, ALERT IIs. However, the pharmacies did not include the name of the facility where a person lived or worked in their documentation.
That leaves the Oregon Health Authority without critical information that could help it identify facilities still at risk of outbreaks and tailor outreach campaigns to long-term care workers. The information also could serve residents and their families who want to know how well protected they are against COVID-19.
And there’s plenty of evidence that the current vaccination rate in long-term care is well below what’s needed to stop deadly outbreaks.
Earlier this month, Phil Bentley, CEO of the Oregon Health Care Association, told state legislators that in his best estimate, only about 50% of long-term care staff have been vaccinated statewide, and rates vary widely from one facility to the next.
There are 30 ongoing outbreaks in long-term care facilities — a significant drop from the peak of over 200 outbreaks reported in January, but still a substantial number.
The auditors recommended that the state require facilities to report the number and percentage of residents and staff who’ve been vaccinated - and make that information publicly available.
In a response to the report, OHA Director Patrick Allen said the agency plans to start asking for that data weekly starting at the end of March. But he didn’t comment on whether OHA will publicly report the data.
Memory care facilities have the highest death rate
Much of the conversation about COVID-19 outbreaks in long-term care has focused on nursing homes — federally regulated facilities that provide 24-hour care to residents.
The conventional wisdom has been that nursing home residents are most at risk of severe or fatal COVID-19 because they tend to be more medically fragile.
But the audit found that the burden of the virus was actually landing harder on facilities providing memory care, a type of residential care setting in which staff have some additional training to work with people with Alzheimer’s and other forms of dementia.
The COVID-19 death rate in facilities with memory care units was more than twice as high as in facilities without them.
Related: The supply and demand conundrum of Oregon’s COVID-19 vaccines
The death rate in memory care facilities was also significantly higher — 14.8 deaths per 1,000 staff and residents — than the death rate in nursing homes, 9.2 deaths per 1,000 residents and staff.
State officials told auditors that the nature of dementia makes it harder to stop the spread of COVID-19 in these facilities, according to the audit: “A common characteristic of people with dementia is their tendency to wander, they noted, making isolation of infected residents a challenge. It is also difficult for these residents to understand why they need to wear masks.”
But the report highlights a number of policy issues that may also be contributing to the outbreaks in memory care.
Almost all of Oregon’s 217 memory care units are located in residential care facilities, a broader type of long-term care known as community-based that is only regulated by the state, not the federal government. People may share rooms in residential care.
The auditors say Oregon has less stringent regulations than the federal government around infection control, staffing and emergency preparedness for community-based care facilities.
“Limited regulation may contribute to higher case and death rates, though other factors may also contribute,” the auditors wrote.
Chasing outbreaks, versus preventing them
According to the review, the state isn’t doing enough to be sure that long-term care staff have received training in how to prevent or contain COVID-19 infection before an outbreak occurs.
As of Nov. 17, 2020 — the height of the pandemic — only 10 of Oregon’s 129 nursing homes had met the federal goal that 50% of staff take free, government-provided infection control training.
The review notes there are multiple reasons why staff may carry the virus into facilities: “They may be asymptomatic and not know they have the virus. Many are low paid and may come to work when sick because they are not paid to stay home or the facility is short-staffed.”
Meanwhile, the state’s executive order process — which is meant to contain COVID-19 and stop transmission once a case has been reported in a facility — may not be fast enough to stop outbreaks of a virus that people can transmit before they’re symptomatic.
“ODHS surveyors try to call or visit facilities within 48 hours of a new executive order to review infection control measures, but by the time a case is reported to ODHS and surveyors have reached the facility, the virus has likely already spread,” the audit said. “This may be particularly true at facilities with infection control issues. Our analysis of the facilities with the 10 highest death totals found surveyors identified infection control issues at seven of them shortly after executive orders were issued but before substantial deaths occurred.”
Related: The double-edged sword of Oregon’s COVID-19 success
Finally, other critical layers of oversight meant to protect residents have been placed on hold during the pandemic.
For example, routine licensing inspections were put on hold in March, following federal guidelines, so state regulators could focus on infection control surveys in facilities with reported cases of COVID-19.
Volunteers for Oregon’s long-term care ombudsmen, who provide independent oversight by taking complaints and talking with residents, haven’t been allowed inside most facilities due to visitation restrictions.
And the Department of Human Services is also behind on responding to complaints about neglect and quality of life due to shifting priorities during the pandemic.
The agencies defended their prevention efforts in a lengthy letter in response to the auditor’s report. They noted that OHA has developed a prevention-focused toolkit to share with long-term care facilities, and has offered education to all facilities — not just those with outbreaks. The agencies are hiring four additional employees to work on containment, including two epidemiologists who specialize in congregate settings.